Diagnosis Of Occult Scaphoid Fractures Research Articles

788 Virtual Scaphoid Fracture Management; How Effective Is It?

Abstract Background The virtual clinic has been used to manage patients out of the hospital setting, decreasing footfall in the hospital, avoiding the need for unnecessary travel and helping decrease carbon footprint. A similar clinic has been running to manage patients presenting to the orthopaedic department with the presentation of suspected scaphoid fracture. As missed scaphoid fractures potentially lead to non-union and complications arising due to it, this study was thought of to see how effective the virtual clinics are in managing suspected scaphoid fractures. Aim To assess a number of suspected scaphoid presentations, and their management. Delay in diagnosis and potential presentation with non-union or SLAC wrist. Method Retrospective data collection for a year of patients presenting to the orthopaedic unit at a busy secondary hospital. The outcome of their presentation associated complications. Results Over a duration of one year from January 2021 to December 2021, 160 patients presented to the virtual clinic. Average age 44yrs. 32% of patients were offered second scaphoid series imaging. 9% of patients underwent MRI with a suspected diagnosis of occult scaphoid fracture. Average gap in second imaging was 21 days. Almost 33% of patients were discharged from virtual clinic with no further need for imaging. 16% of of the suspected cases were confirmed as scaphoid fracture. Conclusions This study highlights the effective use of a virtual clinics in managing scaphoid fractures presenting to a secondary unit.

Can a Deep Learning Algorithm Improve Detection of Occult Scaphoid Fractures in Plain Radiographs? A Clinical Validation Study.

Occult scaphoid fractures on initial radiographs of an injury are a diagnostic challenge to physicians. Although artificial intelligence models based on the principles of deep convolutional neural networks (CNN) offer a potential method of detection, it is unknown how such models perform in the clinical setting. (1) Does CNN-assisted image interpretation improve interobserver agreement for scaphoid fractures? (2) What is the sensitivity and specificity of image interpretation performed with and without CNN assistance (as stratified by type: normal scaphoid, occult fracture, and apparent fracture)? (3) Does CNN assistance improve time to diagnosis and physician confidence level? This survey-based experiment presented 15 scaphoid radiographs (five normal, five apparent fractures, and five occult fractures) with and without CNN assistance to physicians in a variety of practice settings across the United States and Taiwan. Occult fractures were identified by follow-up CT scans or MRI. Participants met the following criteria: Postgraduate Year 3 or above resident physician in plastic surgery, orthopaedic surgery, or emergency medicine; hand fellows; and attending physicians. Among the 176 invited participants, 120 completed the survey and met the inclusion criteria. Of the participants, 31% (37 of 120) were fellowship-trained hand surgeons, 43% (52 of 120) were plastic surgeons, and 69% (83 of 120) were attending physicians. Most participants (73% [88 of 120]) worked in academic centers, whereas the remainder worked in large, urban private practice hospitals. Recruitment occurred between February 2022 and March 2022. Radiographs with CNN assistance were accompanied by predictions of fracture presence and gradient-weighted class activation mapping of the predicted fracture site. Sensitivity and specificity of the CNN-assisted physician diagnoses were calculated to assess diagnostic performance. We calculated interobserver agreement with the Gwet agreement coefficient (AC1). Physician diagnostic confidence was estimated using a self-assessment Likert scale, and the time to arrive at a diagnosis for each case was measured. Interobserver agreement among physicians for occult scaphoid radiographs was higher with CNN assistance than without (AC1 0.42 [95% CI 0.17 to 0.68] versus 0.06 [95% CI 0.00 to 0.17], respectively). No clinically relevant differences were observed in time to arrive at a diagnosis (18 ± 12 seconds versus 30 ± 27 seconds, mean difference 12 seconds [95% CI 6 to 17]; p < 0.001) or diagnostic confidence levels (7.2 ± 1.7 seconds versus 6.2 ± 1.6 seconds; mean difference 1 second [95% CI 0.5 to 1.3]; p < 0.001) for occult fractures. CNN assistance improves physician diagnostic sensitivity and specificity as well as interobserver agreement for the diagnosis of occult scaphoid fractures. The differences observed in diagnostic speed and confidence is likely not clinically relevant. Despite these improvements in clinical diagnoses of scaphoid fractures with the CNN, it is unknown whether development and implementation of such models is cost effective. Level II, diagnostic study.

Thousand shades of gray – The role of imaging display in diagnosis of occult scaphoid fractures – A pilot study

IntroductionMost hospitals and clinics utilize commercial grade displays for viewing wrist radiographs. There is no evidence regarding the role of the imaging display used to evaluate the radiographs. The aim of this study was to compare the rates of scaphoid fracture diagnosis by commercial grade and medical grade displays. MethodsWrist radiographs of patients that had clinical signs of scaphoid fracture without findings on plain radiography (suspected scaphoid fractures) were retrospectively collected from ER department and interpreted for radiographic signs of fracture by four orthopedics seniors commercial grade and medical grade displays. The difference in fracture diagnosis rates were studied. Inter- and intra-observer variability were also studied. ResultsStudy population comprised of 175 high quality wrist radiographs were interpreted. Mean 48.25 (27%) scaphoid fractures were observed on commercial grade display compared to 66 (38.2%) on medical grade display (p = 0.076). The total inter-observer agreement could be defined as a moderate agreement (κ = 0.527, Accuracy = 0.77). Total agreement between all observers were observed in 86 (49.1%) cases compared to 89 (50.9%) cases when reviewing X-rays on commercial and medical displays, respectively. DiscussionThe scaphoid fracture detection rate on medical grade display was not statistically higher compared to non-medical grade displays, but we did find a tendency toward medical grade display. We found that in a substantial number of cases, our observers recognize signs of fracture that were initially evaluated as "suspected fracture" by the ER physicians. As a pilot study, we found evidence that support the need for a prospective study designed to compare the observations to a gold standard modality, such as MRI. We believe utilizing medical grade displays can increase the rate of diagnosis in cases of clinically suspected scaphoid fractures and better manage the clinical scenario of a suspected scaphoid fracture.

The role of ultrasonography in the diagnosis of occult scaphoid fractures.

Background: Ultrasonography is widely utilized by emergency physicians and radiologists to diagnose various orthopaedic diseases, including fractures. We aim to derive a definitive estimate of the diagnostic accuracy of ultrasonography in clinically suspected scaphoid fractures. Methods: We undertook a systematic review and meta-analysis of included diagnostic cohort studies that discussed the use of ultrasonography in the diagnosis of occult scaphoid fractures. We searched the National Institute for Health and Care Excellence database using the Healthcare Databases Advanced Search tool. In addition, we utilized the PubMed database to search the Medical Literature Analysis and Retrieval System Online, Excerpta Medica database, Cumulative Index of Nursing and Allied Health and Allied and Complimentary Medicine databases. Studies were included if they discuss the role of ultrasound imaging in the diagnosis of scaphoid fractures based on cortical interruption, radio-carpal effusion and scapho-trapezium-trapezoid effusion. Quality assessment was performed using the methodological index for non-randomized studies scoring system. Results: 6 non-randomized control studies met the inclusion criteria. Collectively, these included 236 patients with a mean age ranging from 18 to 41.2 years. The quality of these articles ranged between moderate and high based on the methodological index for non-randomized studies score. The mean sensitivity was 88.95% (standard deviation 10.03) and mean specificity was 89.50% (standard deviation 12.21). Conclusion: The current literature reveals high sensitivity and specificity in the use of ultrasonography in scaphoid fracture diagnosis. However, multiple factors including technical differences in ultrasound machines and probes, small sample sizes and variability of subsequent confirmatory tests have created a challenge in determining the ultimate reliability of ultrasonography in the diagnosis of occult scaphoid fractures. Considering these factors and limitations, large-sample and high-quality clinical trials are needed to adequately assess its reliability for this purpose. One stop clinics, in the authors’ opinion, would be an ideal setting for its introduction as well as for future trials.

Digital Tomography for Detection of Acute Occult Scaphoid Fractures.

Diagnosis of occult scaphoid fractures remains a challenge. Traditional management consisting of 2 weeks of immobilization and repeat radiographs results in unnecessary immobilization of many patients without fracture. Magnetic resonance imaging (MRI) is sensitive but expensive. Digital tomography (DT) is an imaging technique that provides fine-cut visualization with minimal radiation exposure and may be used when there is high clinical suspicion despite negative findings on initial radiographs. The authors compared the ability of DT vs MRI to detect acute occult scaphoid fractures. This was an institutional review board-approved, prospective series. Adults for which clinical suspicion for acute scaphoid fracture (presenting within 96 hours of trauma) and negative findings on initial radiographs existed were included. Both a wrist tomogram and MRI were obtained. Wrists were immobilized and reevaluated at 10 to 14 days with repeat radiographs as a control. Studies were interpreted by a radiologist in a blinded fashion. Forty consecutive extremities in 39 patients met the inclusion criteria. Six (15%) of the 40 scaphoids were determined to be fractured on repeat radiographs. Digital tomogram yielded positive findings in 4 of these. Magnetic resonance imaging yielded positive findings in 8 (20%) of the 40 extremities. Sensitivities were 67% and 100% for digital tomogram and MRI, respectively (P=.0001). The positive predictive value was 100% for DT and MRI. The authors found that DT detects more occult scaphoid fractures than initial standard radiographs but is less sensitive than MRI. This is the first study to compare DT with MRI. Digital tomography can be used to augment radiographs and may increase diagnostic efficiency, minimize unnecessary immobilization, and reduce health care costs. [Orthopedics. 2017; 40(6):e1092-e1095.].

Inter-observer agreement between 2-dimensional CT versus 3-dimensional I-Space model in the Diagnosis of Occult Scaphoid Fractures.

The I-Space is a radiological imaging system in which Computed Tomography (CT)-scans can be evaluated as a three dimensional hologram. The aim of this study is to analyze the value of virtual reality (I-Space) in diagnosing acute occult scaphoid fractures. A convenient cohort of 24 patients with a CT-scan from prior studies, without a scaphoid fracture on radiograph, yet high clinical suspicion of a fracture, were included in this study. CT-scans were evaluated in the I-Space by 7 observers of which 3 observers assessed the scans in the I-Space twice. The observers in this study assessed in the I-Space whether the patient had a scaphoid fracture. The kappa value was calculated for inter- and intra-observer agreement. The Kappa value varied from 0.11 to 0.33 for the first assessment. For the three observers who assessed the CT-scans twice; observer 1 improved from a kappa of 0.33 to 0.50 (95% CI 0.26-0.74, P=0.01), observer 2 from 0.17 to 0.78 (95% CI 0.36-1.0, P<0.001), and observer 3 from 0.11 to 0.24 (95% CI 0.0-0.77, P=0.24). Following our findings the I-Space has a fast learning curve and has a potential place in the diagnostic modalities for suspected scaphoid fractures.

Initial experience of SPECT/CT in the diagnosis of occult scaphoid fracture.

Background *Equal contributors.Planar bone scintigraphy (PBS) is often advocated for diagnosing occult scaphoid fractures. PBS is a sensitive diagnostic modality, but lacks specificity, which may result in over-diagnosis.PurposeTo examine, in a pilot study, the potential additional value of single photon emission computed tomography (SPECT) combined with low dose computed tomography (CT) for the diagnosis of an occult scaphoid fracture.Material and MethodsTen patients that underwent combined PBS and SPECT/CT for a clinically suspected scaphoid fracture, where radiographs could not detect a fracture, were included in this pilot study. The PBS and SPECT/CT results were independently and separately evaluated by a nuclear physician for scaphoid fractures and other injuries.ResultsPBS was positive for a scaphoid fracture in four patients and diagnosed three other fractures. SPECT/CT showed five scaphoid fractures and one other fracture. SPECT/CT – PBS had discrepant results in three patients. In two patients PBS diagnosed a trapezoid fracture where SPECT/CT showed a scaphoid fracture. The other patient was diagnosed with a scaphoid fracture on PBS, whereas SPECT/CT showed bone bruise of other carpal bones.ConclusionSPECT/CT has the potential to be more accurate than PBS as it uses anatomical information of the CT to discriminate between the scaphoid, other carpal bones, and bone bruises. Larger studies with an independent reference standard are needed for confirmation of these preliminary data.

Diagnosis of occult scaphoid fractures: a randomized, controlled trial comparing bone scans to radiographs for diagnosis.

Many patients with suspected scaphoid fractures but negative radiographs are immobilized for ≥ 2 weeks and are eventually found to have no fracture. Bone scans are reportedly 99% sensitive for these injuries if done ≥ 72 hours postinjury. The purpose of this study was to determine if early bone scans would allow for shorter cast immobilization periods in patients with suspected scaphoid fractures. Twenty-seven patients with clinically suspected scaphoid fractures and negative radiographs were randomized to early diagnosis (bone scan within 3-5 days; n = 12) or traditional diagnosis (radiographs 10-14 days postinjury; n = 15). The primary outcome was number of days immobilized in a cast. The mean number of days immobilized was 26 in the traditional group and 29 in the bone scan group. Overall, 6 patients had scaphoid fractures (2 in the traditional diagnosis group and 4 in the bone scan group; p > 0.05), and 8 had other types of fractures. These other types of fractures included four distal radius fractures, two triquetral fractures, one trapezoid fracture, and one hamate fracture. There was no significant difference in the number of other types of fractures between groups. The Kaplan-Meier survival analysis using the log-rank test revealed that there was no statistically significant difference between days immobilized between the radiograph and bone scan groups (p = 0.38). The current study suggests that the use of bone scans to help diagnose occult scaphoid fractures does not reduce the number of days immobilized and that the differential diagnosis of occult scaphoid fractures should remain broad because other injuries are common.

Computed Tomography for Suspected Scaphoid Fractures: Comparison of Reformations in the Plane of the Wrist Versus the Long Axis of the Scaphoid

Definitive diagnosis of occult scaphoid fractures remains difficult. We tested the null hypothesis that, for diagnosis of true fractures among suspected scaphoid fractures, computed tomography (CT) reformations along the long axis of the scaphoid have the same accuracy as reformations made relative to the anatomical planes of the wrist. In a prospective trial, 34 patients with a suspected scaphoid fracture underwent CT scanning within 10days after trauma. CT reformations along the long axis of the scaphoid (CT-scaphoid) and along planes relative to the wrist (CT-wrist) were made. We used radiographs obtained 6weeks after injury as the reference standard for a true fracture. A blinded panel including two surgeons and one radiologist came to a consensus diagnosis for each reformation plane. The reference standard showed six fractures of the scaphoid (prevalence, 18%). Using CT-wrist, a scaphoid fracture was diagnosed in five patients (15%), with three false positive, four false negative and two true positive diagnoses. Using CT-scaphoid, a scaphoid fracture was diagnosed in five patients (15%), with one false positive, two false negative and four true positive results. Sensitivity, specificity and accuracy were 33, 89 and 79% for CT-wrist and 67, 96 and 91% for CT-scaphoid, respectively. This resulted in positive predictive values of 36% for CT-wrist and 76% for CT-scaphoid. Negative predictive values were 87% for CT-wrist and 94% for CT-scaphoid. No significant differences were found with the number of patients available. For diagnosis of true fractures among suspected scaphoid fractures, the diagnostic performance characteristics of CT scans reformatted along the long axis of the scaphoid were better than CT scans in the planes of the wrist, but the differences were not significant.

Morbidity in adults with a normal limited scaphoid MRI: a retrospective cohort study and follow-up questionnaire

IntroductionThe scaphoid bone is the most commonly fractured carpal bone. MRI is now recognised to be more sensitive and specific than serial plain films in the diagnosis of occult scaphoid...

Commentary on an article by Wouter Mallee, MSc, et al.: “Comparison of CT and MRI for Diagnosis of Suspected Scaphoid Fractures”

Despite extensive study, the optimal imaging modality for the diagnosis of a suspected scaphoid fracture remains controversial. Traditionally, patients with clinical findings consistent with scaphoid fracture but with negative initial radiographs have been managed with splint or cast immobilization followed by repeat clinical and radiographic examination two weeks following injury. However, given the relatively low prevalence of true fractures in this population, the classical approach has been criticized for overtreating a majority of these patients. To avoid diagnostic delay and unnecessary immobilization, advanced imaging techniques have gained popularity to facilitate early definitive diagnosis of scaphoid fractures. Studies advocating the use of magnetic resonance imaging (MRI), computed tomography (CT), bone scintigraphy, and ultrasound in the evaluation of suspected scaphoid fractures are plentiful. Among these imaging modalities, MRI has emerged as a relative gold standard, due to both its excellent reported diagnostic performance as well as its ability to identify alternate causes of wrist pain. Criticisms of MRI have been that it is susceptible to misinterpretation of injuries such as bone bruises, potentially resulting in false positive results, and that it has limited capacity to demonstrate subtle degrees of fracture displacement. The use of CT in the acute diagnosis of scaphoid fractures is less well documented but has been advocated because of its lower costs and widespread availability, although the diagnostic accuracy of CT in this situation has been questioned1. Although current institutional protocols vary, an often recommended algorithm is to first proceed …

Clinical Examination of Scaphoid Fractures

Undetected scaphoid fractures may lead to complications, including nonunion, malunion, avascular necrosis, and wrist arthritis. A competent physical examination is essential for the diagnosis of scaphoid fractures in the setting of occult fractures presenting with normal radiographs. The differential diagnosis of occult scaphoid fractures includes acute tears of the scaphoid-lunate ligament, Kienbock's disease, occult ganglion, nondisplaced radial styloid fractures, and injury to the radial aspect of the radio-scapho-capitate ligament. All of these may have normal plain radiographs but often can be distinguished based on physical examination findings. The 2 key points of such an examination include the exact location of point tenderness and provocative special tests. Although Watson's scaphoid shift test is classically described for scaphoid instability, we highlight its significance in the setting of scaphoid fractures.

Is intrasound vibration useful in the diagnosis of occult scaphoid fractures?

This study was designed to confirm the results of Finkenberg et al. (J Hand Surg 1993;18A: 4-7), who found a high sensitivity (100%) and specificity (95%) of the intrasound vibration method in diagnosing occult scaphoid fractures. These occult scaphoid fractures are not visible on x-ray films, but clinically the patients are suspected of having a scaphoid fracture. A vibratory apparatus is placed over the anatomical snuff-box and a vibration of 100 mW is emitted; a painful sensation is produced if the scaphoid is fractured. Thirty-seven consecutive patients with a clinically suspected scaphoid fracture were evaluated. In 6 patients, a scaphoid fracture was radiographically identified; in the remaining 31 patients, a 3-phase bone scan was obtained. Eleven wrists showed increased uptake over the scaphoid and were considered to have an occult scaphoid fracture. In this group, bone scintigraphy was used as the reference standard. The vibration test was painful in 1 of 6 patients with a proven scaphoid fracture and in 3 of the 11 patients with a positive bone scan. In contrast to the results of Finkenberg et al, the intrasound vibration method shows a sensitivity of 24%, a specificity of 85%, a positive predictive value of 40%, and a negative predictive value of 65%. We conclude that the accuracy of intrasound vibration is low and that it is not useful in the diagnosis of scaphoid fractures.

Diagnosis of occult scaphoid fractures by intrasound vibration

We investigated a new means of diagnosing occult scaphoid fractures. Eighty-six patients underwent vibratory testing at presentation, while the clinical examination and standard four-view x-ray examination findings were unknown to the persons who performed the vibratory testing of both the injured and uninjured wrists. Thirty-six patients had radiographically confirmed scaphoid fractures and, after their vibratory tests, were eliminated from the study. Fifty patients, 39 men and 11 women, were believed to have scaphoid fractures on the basis of history and clinical examination findings but were included in the occult scaphoid study group because standard four-view x-ray films of the wrists did not reveal a scaphoid fracture. Distinction between the fracture and no-fracture patients was made with a limited two-phase technetium bone scan and delayed x-ray examination. All patients with known scaphoid fractures (36) had positive findings on vibratory examination. Vibratory testing identified all six of the patients with occult scaphoid fractures (sensitivity 100%). Results of two examinations were false-positive, and none were false-negative (specificity 95%). One of the patients with false-positive results had a fracture of the trapezium, and the other had reflex sympathetic dystrophy. The vibratory testing of injured wrists is inexpensive, noninvasive, and easy to perform, and it involves no ionizing radiation.

Radiography of the carpal scaphoid. Experimental evaluation of "the carpal box" and first clinical results.

The authors describe a new device ("the carpal box") for the radiographic detection of occult scaphoid fracture. Fractures in the scaphoid of five cadaver specimens were mechanically produced. Subsequent examinations included conventional scaphoid radiography, multi-angle radiography, and radiography using the new device. The anatomic analysis of the specimens served as the standard for comparison. A pilot study was performed in six consecutive patients with suspected scaphoid fracture. Neither scaphoid radiography nor multi-angle radiography could confirm a fracture in two specimens, whereas all fractures were recognized on the carpal box radiographs. All scaphoid fractures were visualized by carpal box radiography, whereas scaphoid radiography was equivocal in one patient and negative in the other. Carpal box radiography may have additional value in the diagnosis of occult scaphoid fracture. This may lead to a reduction in costs and inconvenience for patients with clinically suspected scaphoid fracture and negative scaphoid radiography.